Why WASH Matters to People Living With HIV

Joe BrownLondon School of Hygiene & Tropical MedicineDepartment of Disease ControlFaculty of Infectious & Tropical Diseases

joe.brown@lshtm.ac.uk25 July 2012

WASH importance to HIV• Quality of LIFE• OIs related to WASH disproportionately affect

People Living With HIV (PLHIV)• Stakes are higher for PLHIV: increased

morbidity & mortality• Co-infections can lead to disease progression

and early death as infections result from and increase a weakened immune status

• Gut infections reduce ART uptake!

WHO GBD 2008, LMICs

Some common co-infections that may be prevented or reduced with WASH• Faecal-oral

– Hepatitis A,E; viral diarrheas; Campylobacter; cholera; ETEC; Salmonella; Shigella; typhoid; paratyphoid; Crypto; Giardia; Amoebas; Toxoplasma gondii and other opportunists

• Water-washed– Trachoma; scabies; conjunctivitis; louse-borne infections

• Soil helminths and tapeworms– Ascaris; hookworm; Taenia

• Water-based– Cholera; Legionella; Leptospirosis; Schisto;

• Insect vectors– Dengue, yllw fever, malaria, trypanosomiasis, filariasis, trachoma

• Rodent borne– Leptospirosis; hantavirus, Tularemia

WASH control measures• Improve water quality, water availability, hygiene

– Hepatitis A,E; polio; viral diarrhoeas; Campylobacter; cholera; ETEC; Salmonella; Shigella; typoid; paratyphid; Crypto; Giardia; Amoebas; Toxoplasma gondii and other opportunists

• Improve water availability and hygiene– Trachoma; scabies; conjunctivitis; louse-borne infections

• Sanitation, hygiene, treatment of excreta before re-use– Ascaris; hookworm; Taenia

• Reduce contact with contaminated water, sanitation, treatment of excreta before re-use– Cholera; Legionella; Leptospirosis; Schisto; Guinea worm

• Drainage, reducing breeding sites, insecticides/nets– Dengue, yllw fever, malaria, trypanosomiasis, filariasis, trachoma

• Rodent control, hygiene measures– Leptospirosis; hantavirus, tularemia

Children with HIV• Children who are HIV+ are at much greater risk

of hospitalization, long-term illness, and death as a result of WASH-related infections

• Children who are HIV+, as well as those who are HIV- but cared for by mothers that are HIV+, are at greater risk of poor nutritional status and health which can be caused or aggravated by enteric infection (Filteau 2009)

ART and diarrhea• Diarrheal disease and

intestinal infection may cause individuals on antiretroviral therapy (ART) not to absorb therapeutic dosages of the medication (Isaac 2008, Brantley 2003, Bushen 2004).

• Implications for PMTCT, PREP, PEP, long-term disease progression and survival

Prevention of Mother-to-Child Transmission (PMTCT)• Healthier moms are less likely to transmit

the virus to children through breastfeeding– Healthier moms are less likely to pass other

infections to baby, also • Gut infections in babies may increase the

risk of HIV infection by compromising the integrity of the intestinal wall, making it easier for the HIV virus to pass into the infant’s bloodstream

• Safe water and hygiene play a major role in the limited circumstances when replacement feeding/early weaning are indicated

Retention in care• Increased retention in care as a result of VitaMeal

and hygiene packages (soap, P&G packets/cloth+ storage container) offered

• Also reported “99.4% usage” of water treatment at 3 month follow up, versus 12% (disinfectant use among mothers with young children) or 20% (all households in Malawi)

Rosen S, Fox MP, Gill CJ (2007) Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review. PLoS Med 4(10): e298. doi:10.1371/journal.pmed.0040298http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0040298

Cost effectiveness• Low cost of including WASH in treatment and

care programs– Pennies on the dollar! – Sustained access to safe water would be <5% of the

cost of first-line ARVs (drugs only)• Significant net savings with integrated

programming (Khan et al 2012)• Benefits of hygiene and safe water programs

can extend beyond antenatal beneficiaries to include friends and relatives (Russo et al. 2012)

What we can do nowAdd WASH to HIV PMTCT programming because:

• 1. We know HIV-affected children and adults are highly vulnerable to diarrheal illnesses

•2. We know that WASH interventions can reduce diarrhea by 50% or more• 3. We know that diarrhea in mothers and

children can contribute to lower uptake of life-saving drugs that prevent MTCT

• 4. We know it can increase retention in treatment and care, at low cost

Thank youCreative and Novel Ideas in HIV Research (NIH)

P&G

London School of Hygiene and Tropical Medicine, Environmental Health Group

University of Zambia School of Medicine

Charlie Van Der Horst & the UNC CFAR